3.1 Products for environmental cleaning
Best practices for environmental cleaning products
These are the best practices for environmental cleaning products (e.g., detergents, disinfectants):
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- Develop and maintain a master list of facility-approved environmental cleaning products in the facility cleaning policy, as well as a list of approved suppliers (i.e., manufacturers, distributors).
- Minimize the number of different environmental cleaning products in use at the facility. Clearly stating this in the facility cleaning policy will:
- Simplify the environmental cleaning process.
- Minimize the training requirements for cleaning staff.
- Reduce the potential for errors in preparation and use.
- Store environmental cleaning products in a manner that:
- Eliminates contamination risk and degradation.
- Minimizes contact with personnel (e.g., inhalation, skin contact).
- Manage environmental cleaning products according to the product's safety data sheet (SDS). Display the SDS where these products are stored and prepared.
- Prepare cleaning and disinfectant solutions according to manufacturer's instructions. Preparing higher-strength concentrations or diluting beyond recommendations may pose unnecessary risk to patients, staff, visitors, and the environment.
- Ensure that environmental cleaning products selected do not damage the surfaces and equipment to be cleaned and disinfected.
- Ensure that standard operating procedures or instructions are available for the preparation, use, and disposal of environmental cleaning products.
3.1.1 Cleaning products
Cleaning products include liquid soap, enzymatic cleaners, and detergents. They remove organic material (e.g., dirt, body fluids) and suspend grease or oil. This is done by combining the cleaning product with water and using mechanical action (i.e., scrubbing and friction).
For most environmental cleaning procedures, select neutral detergents (pH between 6 and 8) that are easily soluble (in warm and cold water).
There are also specialized cleaning products, which may provide advantages for specific areas or materials within the healthcare facility (e.g., bathroom/toilet cleaners, floor polishers, glass cleaners). However, consider specialized products on a case-by-case basis, weighing the advantages and disadvantages (e.g., additional cost) and ability of the facility to ensure the correct storage, preparation, and use.
3.1.2 Disinfectants
Disinfectants are only for disinfecting after cleaning and are not substitutes for cleaning, unless they are a combined detergent-disinfectant product. See 3.1.3. Combined detergent-disinfectants. Before disinfecting, use a cleaning product to remove all organic material and soil.
Low-level disinfection is generally adequate for environmental cleaning procedures, but there are specific cases where intermediate-level disinfection with sporicidal properties (e.g., C. difficile) is required. See 4.6.8 Transmission-based precaution/Isolation wards.
Common low- and intermediate-level disinfectants that can be used for environmental surfaces in healthcare settings include:
- Quaternary ammonium compounds.
- Alcohol (ethyl or isopropyl).
- Chlorine releasing agents (e.g., bleach).
- Improved hydrogen peroxide.
Table 4 (below) shows the main advantages and disadvantages of each of these disinfectants. In practice, the advantages and disadvantages of each product will have to be weighed with other factors, including availability and cost.
Do not use these products for disinfection of environmental surfaces and noncritical patient care equipment:
- Liquid chemical sterilant or high-level disinfectants (e.g., glutaraldehyde, peracetic acid, orthophthaldehyde).
- Antiseptics (e.g., chlorhexidine, iodophors).
- Phenolics (due to high toxicity).
Table 4. Advantages and disadvantages of common healthcare disinfectants (modified from reference 241)
Low-level disinfectant & Spectrum of activity
Low-level disinfectant
Quaternary ammonium compounds such as:
- Alkyl dimethyl benzyl ammonium chloride
- Alkyl dimethyl ethylbenzyl ammonium chloride
Spectrum of activity
- Bactericidal
- Virucidal (only enveloped viruses)
- Fungicidal
Advantages and Disadvantages
Advantages
Disadvantages
Toxicity:
- may be used on food contact surfaces.
Wide material compatibility:
Detergent properties, with good cleaning ability
Low cost
Toxicity:
- skin irritant, can also cause respiratory irritation
Narrow microbiocidal spectrum:
- not mycobactericidal or sporicidal, only limited activity against non-enveloped viruses
- diluted solutions can support growth of microorganisms, particularly gram negative organisms
Affected by environmental factors:
- activity reduced by various materials (e.g., cotton, water hardness, microfiber cloths, organic material)
- could induce cross resistance with antibiotics
- persists in the environment and waterways
Intermediate-level disinfectant & Spectrum of activity
Intermediate-level disinfectant
Alcohols (60-80%) such as:
- isopropyl alcohol
- ethyl alcohol
- methylated spirits
Spectrum of activity
- Bactericidal
- Virucidal
- Fungicidal
Advantages and Disadvantages
Advantages
Disadvantages
Broad spectrum (but not sporicidal)
Rapid action
Nontoxic
Non-staining, no residue
Noncorrosive
Low cost
Good for disinfecting small equipment or devices that can be immersed
Slow acting against non-enveloped viruses
Does not remain wet.
- rapid evaporation makes contact time compliance difficult (on large environmental surfaces).
Affected by environmental factors:
- inactivated by organic material.
Material compatibility:
- can damage materials (plastic tubing, silicone, rubber, deteriorate glues).
Flammable
Intermediate-level disinfectant & Spectrum of activity
Intermediate-level disinfectant
Chlorine releasing agents such as:
- bleach/sodium or calcium hypochlorite
- sodium dichloroisocyanurate (NaDCC)
Spectrum of activity
- Bactericidal
- Virucidal
- Fungicidal
- Mycobactericidal
- Sporicidal (hypochlorites only at ppm or 0.5%)
Advantages and Disadvantages
Advantages
Disadvantages
Hypochlorites are broad spectrum (sporicidal)
Rapid action
Nonflammable
Low cost
Widely available
Can reduce biofilms
Affected by environmental factors:
- inactivated by organic material.
High toxicity:
- can release toxic chlorine if mixed with acids or ammonia.
- skin and mucous membrane irritant.
Material compatibility:
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- damages fabrics, carpets.
- corrosive
Leaves residue, requires rinsing or neutralization.
Offensive odors
Poor stability:
- subject to deterioration if exposed to heat and UV.
Intermediate-level disinfectant & Spectrum of activity
Advantages and Disadvantages
Advantages
Disadvantages
Rapid action
Nontoxic
Detergent properties, with good cleaning ability
Not affected by environmental factors
- active in the presence of organic material
Safe for environment
Can reduce biofilms
Material compatibility:
- contraindicated for use on
- copper,
- brass,
- zinc,
- aluminum
High cost
3.1.3 Combined detergent-disinfectants
Combined (one-step) detergent-disinfectant products can generally be used in place of a two-step (separate detergent and disinfectant product) process when disinfection is indicated for specific environmental cleaning procedures. See 4. Environmental Cleaning Procedures.
Do not use a combined (one-step) detergent-disinfectant product (instead use a two-step process) when performing environmental cleaning for:
- C. difficile—see 4.6.8 Transmission-based precaution/Isolation wards.
- Spills of blood or bodily fluids—see 4.5 Spills of blood or body fluids.
When using a combined product for environmental cleaning, it is recommended to periodically (i.e., on a scheduled basis) use a rinse step to remove residues from surfaces. Additionally, care should be taken to ensure that the combined product stays wetted on the surface for the required contact time (to complete the disinfection process). Consult the product label to get the correct contact time.
3.3 Supplies and equipment for environmental cleaning
Essential supplies and equipment for environmental cleaning
Surface cleaning supplies:
- Portable containers (e.g., bottles, small buckets) for storing environmental cleaning products (or solutions).
- Surface cleaning cloths.
Floor cleaning supplies:
- Mops or cleaning squeegee with floor cloth.
- Buckets.
- Wet floor/caution signs.
Do not use these cleaning supplies and equipment for disinfection of environmental surfaces and noncritical patient care equipment:
- Brooms and dry mops.
- Fumigators (and fumigation) and disinfectant fogging.
- Spray bottles: Use squeeze bottles instead.
In general, all the essential environmental cleaning supplies and equipment are reusable, but facilities can also choose to use disposable supplies (e.g., cloths) for certain cleaning tasks or where resources allow. Cleaning equipment should be:
- Fit for the intended purpose.
- Cleaned and stored dry between uses.
- Properly used.
- Well maintained; see 3.5 Care and storage of supplies, equipment, and personal protective equipment.
Consider purchasing supplemental supplies and equipment such as toilet brushes or abrasive pads for cleaning certain surfaces or areas. Some facilities might also have access to more sophisticated equipment such as floor scrubbers or vacuum cleaners with high-efficiency particulate air (HEPA) filters. If the use of HEPA filters is part of the facility policy, provide an SOP on its cleaning and maintenance.
Surface cleaning supplies
Portable containers for environmental cleaning products (or solutions) should be clean, dry, appropriately-sized, labelled, and dated.
- Narrow-necked bottles are preferred over buckets to prevent the "double-dipping" of cleaning cloths, which can contaminate solutions.
- Squeeze bottles are preferred over spray bottles for applying cleaning or disinfectant solutions directly to cleaning cloths before application to a surface.
Surface cleaning cloths should be cotton or microfiber (disposable wipes can be used if resources allow). Have a supply of different colored cloths to allow color-coding: for example, one color for cleaning and a second color for disinfecting. Color-coding also prevents cross-contamination between areas, like from toilets to patient areas, or isolation areas to general patient areas. For example, red cloths could be used specifically for toilet areas, blue for general patient areas, and yellow for isolation areas.
Floor cleaning supplies
Mop heads or floor cloths should be cotton or microfiber.
- Use a cart or trolley with two or three buckets for the mopping process—see 3.3.1 Preparation of supplies and equipment.
- It is highly recommended to display a wet floor/caution sign before starting mopping activities.
Microfiber versus cotton
Give careful consideration to the type of material before purchasing cleaning cloths.
Microfiber cloths are often preferred over cotton for both cleaning cloths and mop heads because microfiber absorb more dirt and microorganisms than cotton. However, microfiber cloths can be damaged by high pH and therefore are not compatible with all disinfectant products (especially chlorine-based). They need to be laundered separately from cotton cloths/linens, which could be expensive.
Disinfectant or detergent-disinfectant wipes
Prepared (ready-to-use) wipes that are saturated with an appropriate disinfectant or detergent-disinfectant product can be used as an alternative to cotton or microfiber cleaning cloths. Take care to evaluate the appropriateness of the product, considering the recommended properties. It is also important to ensure that they are stored appropriately with the lid closed so the wipes remain wet. Discard wipes if they are no longer saturated. Follow manufacturer's instructions for storing wipes and reprocessing containers, as well as instructions for use (e.g., recommended contact times).
3.3.1 Preparation of supplies and equipment
Daily preparation of supplies and equipment for a given cleaning staff member or location will depend on local factors, including the size of patient care areas and number and type of patient zones to be cleaned.
Cleaning carts and trolleys
- Cleaning carts and trolleys provide several benefits, such as the ability to carry and safely manage all the essential cleaning supplies and equipment and increased occupational safety for cleaning staff.
- Stock cleaning carts with sufficient quantities of supplies (e.g., cleaning cloths, cleaning solutions) to avoid the need to return for more supplies in the middle of cleaning in a particular patient care area.
Best practices for cleaning carts and trolleys
- Separate clean and soiled items (e.g., cleaning cloths).
- Never put personal items, food, or beverages in them.
- Equip them with a lockable compartment for containers of cleaning and disinfectant solutions.
- Thoroughly clean them at the end of each day or shift—see 3.5 Care and storage of supplies, equipment, and personal protective equipment.
- While in use, never leave them unattended or out of your sight.
- When not in use, store them in a designated environmental cleaning services area.
Surface cleaning supplies
Portable containers of environmental cleaning products (or solutions) and cleaning cloths can be carried directly on the cleaning cart or on a caddie kit, if a full cleaning cart is not available.
The cart should have enough cleaning cloths to complete the required cleaning session, with a clean cloth for each patient zone to prevent cross-contamination. Keep clean and soiled cloths separate. Place clean clothes in one container or section of the caddie and soiled cloths in another.
Floor cleaning supplies
It is best practice to use a two- or three-bucket system for mopping. This can be facilitated on the cleaning cart or on a separate trolley if a full cleaning cart is not available.
- Two-bucket system (routine cleaning): One bucket contains a detergent or cleaning solution and the other contains rinse water (Figure 7).
- Three-bucket system (for disinfection): One bucket contains the detergent or cleaning solution, one contains rinse water, and one the disinfectant or disinfectant solution (Figure 8).
The rinse water bucket allows the mop to be rinsed and wrung out before it is re-dipped into the prepared solution. This extends the life of the solution (i.e., fewer changes are required), which saves both time and material costs.
3.5 Care and storage of supplies, equipment, and personal protective equipment
Environmental cleaning supplies and equipment quickly become contaminated during their use. Regularly reprocess all reusable items (i.e., thoroughly clean, disinfect, and dry).
Best practices for reprocessing reusable cleaning supplies and equipment
- Send all reusable supplies and equipment (e.g., buckets, rubber gloves) for reprocessing:
- Directly after use in a transmission-based precaution area.
- When soiled with blood or body fluids.
- Thoroughly clean, disinfect, and rinse equipment such as buckets and containers whenever solution is replaced and daily. Store them upside down to allow complete drying.
- Launder mop heads, floor cloths, and soiled cleaning cloths at least daily (e.g., at the end of the day) and allow them to fully dry before storage and reuse.
- Reprocess all reusable supplies and equipment in a dedicated area that is not used for other purposes (i.e., reprocessing of cleaning equipment should never be conducted in handwashing sinks).
- Reprocess (e.g., launder) all reusable supplies and equipment according to manufacturer's instructions.
Manual reprocessing steps
If manufacturer's instructions are not available, use this general process to manually reprocess reusable supplies, equipment, and PPE:
- Immerse in detergent solution and use mechanical action (e.g., scrubbing) to remove soil.
- Disinfect by:
- Fully immersing the items in boiling water or
- Fully immersing the items in disinfectant solution for the required contact time and rinsing with clean water to remove residue.
- Allow to fully dry
- Lay items to dry in a clean and dry area to prevent recontamination.
- Position mops with the head up to allow the mop head to fully dry.
Do not use chlorine-based disinfectants to disinfect microfiber cloths.
Use laundry services with hot water (70–80°C x 10 min) [158–176°F] to reprocess cloths and mop heads if they are available. Similarly, a commercial dryer can be used for these items if available (if not, these items are reprocessed as above).
Always launder mop heads and cleaning cloths separately from other soiled hospital textiles.
All reusable supplies and equipment should be well maintained, clean, and in good repair. Regularly inspect and replace or repair all reusable equipment when needed. Develop a facility monitoring and maintenance schedule that clearly documents reusable supplies and equipment, frequency of inspection, and responsible staff.
Certain equipment, such as floor polishers, might require maintenance checks by qualified people according to the manufacturer's instructions. Keep a service record and make it available for inspection by the cleaning program manager and the IPC Team.
Environmental cleaning services area
Designate at least one environmental cleaning services area within the facility for preparation, storage, and reprocessing of reusable cleaning equipment and supplies. This area should not be used for any other purposes. For multistory facilities, it is best practice to have one of these areas on each floor.
The designated environmental cleaning services area should:
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- Be well-ventilated and illuminated (lighting or window access).
- Be labeled with a biohazard sign on the door.
- Have an appropriate water supply (hot and cold water access, if feasible).
- Have a utility sink/floor drain for safe disposal of used solutions.
- Be designed so that, whenever possible, buckets can be emptied into utility sink/floor drains without lifting them or creating splashes.
- Have a dedicated handwashing sink, used only for handwashing.
- Have access to an eyewash station.
- Have appropriate PPE available.
- Have enough space to keep reprocessing (dirty areas) separate from storage areas for cleaned equipment.
- Be easily accessible in relation to the areas it serves (i.e., easily accessible throughout the facility).
- Be appropriately sized to the amount of materials, equipment, and chemicals stored in the room/area.
- Have printed copies of the SDS for all environmental cleaning products, manufacturer's instructions, and job aids for preparation of cleaning and disinfectant solutions.
- Never contain personal clothing or grooming supplies, food, or beverages.
- Have a separate area for cleaning staff to store these items.
- Have safe chemical storage and access.
- Have locks fitted to all doors to restrict access only to cleaning staff.
- Be free from clutter.
- Have washable surfaces (floors, walls, shelves).